What Every Therapist Needs to Know About Anxiety Disorders

by Martin N Seif

  Next, frame anticipatory anxiety as a learning experience about the power of the brain to affect feelings. While anticipatory anxiety is real anxiety, it a type of anxiety that is generated by mental images, independent of external causes. Closely observing instead of trying to suppress anticipatory anxiety will help to grasp the power of the mind to create its own version of reality. Suggest changing “what if” to “what is,” thereby redirecting the patient’s attention to the present moment when he finds himself stuck in images of the future. We repeatedly remind patients to stay in the “now.” Again, this is best accomplished by redirecting attention from cognition and thinking to the senses (“What do you hear, see, smell? Notice the floor under your feet. Pay attention to the coolness of air you breathe in compared with the warmth of the air you breathe out, etc.”).

  Here is a particularly vivid example. A patient had a severe phobia of vomiting (emetophobia), and was so terrified about it that she limited her life enormously. She avoided anyone whom she believed might be ill, since that person might pass on a stomach virus and cause her to throw up. She lived in an apartment with a roommate with whom she was friendly, but not very close. Each had their own bedroom and bathroom. One morning she and her roommate lingered over breakfast, and both went to work at the same time. That evening she returned home to find that her roommate’s door was shut and she could hear definite signs that her roommate was coughing, retching, and throwing up. “What if,” she thought, “she caught her roommate’s stomach virus and would soon start getting nauseous and vomiting herself?” That night was a horror. She was afraid to knock on the door and contact her roommate. She couldn’t sleep, and spent most of the night with intense anticipatory anxiety, waiting for her own nausea and vomiting to begin. Finally, out of exhaustion, she fell asleep until the morning. When she awoke, she saw her roommate walking around the apartment, smiling pleasantly, sipping coffee, eating breakfast, and reading the paper. “But I thought you were sick last night?” my patient asked, “How did you recover so quickly?” Her roommate looked a little surprised, then laughed a bit, and said that she had been fine all night, but saw the movie “Detroit Rock City” on a DVD before going to bed. There was an explicit scene in the movie where someone throws up, and she guessed that my patient had overheard that scene.

  This woman immediately realized that her roommate had never been ill, and that there had never been a danger of catching her stomach virus. The entire experience was based on misinformation, and was entirely generated in the mind of the patient. It was the beginning of a profound realization that her fear was triggered by images in her brain, and not by the external reality.

  Weekes (1976) notes that anticipatory anxiety is always the last to go because patients need to build up a new set of less distressful experiences in order to override memories of intense situational fear. The best way to overcome anticipatory anxiety is to relate to it for what it is: an automatic misleading message that is best allowed and ignored. The result is that anticipatory anxiety has the opportunity to become increasingly relegated to the background of awareness. That way, it no longer matters.

  The Reassurance Junkie: When People Are Constant Callers

  Some patients spend an extraordinary amount of energy looking for reassurance. Here are some examples.

  A 25-year-old female hates it whenever she believes a friend or colleague might be angry at her.

  PATIENT: So I text them and tell them I hope I didn’t offend them.

  THERAPIST: Do you think you did? Offend them?

  PATIENT: Most of the time, “no.” but I can’t really be sure. I go over in my mind what I said, and I hope they didn’t take it the wrong way. But the worst part is that I text them and apologize even when they treat me poorly.

  A 55-year-old male repeatedly calls his doctor because of a feared symptom.

  PATIENT: I have this burning in my throat that makes me very nervous that I might have cancer. And I feel so stupid calling the doctor about it.

  THERAPIST: Why is that?

  PATIENT: Because I called him last month about it. And I got an upper endoscopy and he said I’m fine. But now I’m having this burning again. So I called his office and spoke with the doctor again. He is very nice, and he said there is nothing wrong with my throat. But as soon as I got off the phone, I worried that maybe he had mixed me up with another patient, but I was too embarrassed to call him again.

  THERAPIST: So what did you do?

  PATIENT: I made an appointment with another doctor.

  A 47-year-old female continually asks to be calmed down during an airplane flight.

  PATIENT: During the flight I’m a basket case. I look at the flight attendants to make sure they look relaxed and not frightened. I use the call button all the time, and ask about sounds that I hear that seem unusual. I make my husband tell me that the flight will go well. I need to know everything is okay or else I start to panic. When the turbulence starts I beg the flight attendant to stay with me.

  This 37-year-old female wants to know exactly where her husband is every single minute.

  PATIENT: I get very nervous when he is away. I worry a lot that something awful might happen to him. I have all these crazy ideas that he’ll be hurt or get into an accident and I can’t get them out of my mind.

  THERAPIST: So what do you do?

  PATIENT: I have him call me when he gets into his office. And then I relax a bit. And then I like to know where he goes for lunch, if he goes out for lunch. And when he gets back to the office he calls to let me know he is back safe and sound. And then my husband has to call me when he leaves the office, so I know when I should start worrying if he is late.

  THERAPIST: And what happens if he is late?

  PATIENT: First I call and ask where he is. If I can’t get him, I get really scared, and start checking the news to see if there are any accidents.

  The list is long and varied: the dependent employee who calls the supervisor for approval before even the most trivial decision. The spouse who asks her husband to reassure her each bedtime that she won’t go crazy during the night. The driver who wants her mother to guarantee that she won’t freak out while driving over a bridge. The mother who puts her child on the school bus, then calls her friends to tell her she is not being irresponsible. The person who combs the internet for websites and chat groups compulsively, often re-reading the same information to reassure himself that he does not have some medical or psychological problem. One patient with panic disorder was afraid to go into the park for fear she would panic and rip off her clothes. She repeatedly asked for guarantees that she wouldn’t do that.

  A caring and competent therapist mentioned a patient who had developed an unusual and intense “dependency”: he called her regularly, told her about colored spots he saw on the ground, and asked if she thought that the spots could be blood. She would answer “no” about any spots that weren’t red, and the patient would hang up, seemingly satisfied. The therapist was concerned that these phone calls were increasing in frequency, and indicated an attempt to expand treatment outside of the office.

  These patients often contact the therapist for reassurance as well. Their calls are different from the occasional calls that patients may make during genuine crises. They may be for approval of a decision, assurance that they did something correctly, a guarantee that they aren’t having a heart attack or a stroke, confirmation of an appointment time, clarification of an issue discussed in session, a discussion of a new anxiety or returning symptom, permission that it is all right to call between sessions, apologizing over something said in session or for calling too much, or a seemingly endless list of “issues” that pop up and need urgent soothing.

  What These Patients Have in Common

  While some might describe these people as dependent or manipulative, they all suffer from intense anxiety, and—while their specific diagnoses may be different—they all share a similar and unsuccessful method of coping with their anxiety: they require other pe
ople to reassure them that their fears are unjustified. There is a place for reassurance in therapy. Most people benefit from empathic and realistic reassurance when they are coping with the normal anxiety associated with change—trying out new ways of coping, making hard life decisions, confronting difficult people. The majority of the time, reassuring patients helps them over hurdles, and leads to greater confidence and decreased anxiety. Sometimes a patient will say, “This is new to me. I have no perspective. Does it seem like I’m handling this in a way that makes good sense?” And you will—when you think it appropriate—use reassurance as a means to keep anxiety manageable.

  But for certain anxious patients, reassurance has the opposite effect. While it decreases anxiety for a short period of time, the anxiety soon returns with a vengeance. This surge of anxiety is followed by an increased need for further reassurance. And the cycle continues. The cycle of behavior is analogous to the heroin addict, who temporarily feels beatific after a fix, but then has an increased craving for the drug when it wears off. The reassurance “fix” keeps anxiety manageable for a time, but anxiety reappears when it wears off, necessitating yet another reassurance. These people are reassurance junkies!

  We have emphasized that a very powerful way of temporarily keeping anxiety at bay is to gain assurance there is nothing to worry about—that there is no basis for concern. For certain patients, whenever anxiety is triggered, the quest for reassurance becomes driven and compulsive, and we view this obsessive need for reassurance as OCD, independent of any additional issues. Reassurance compulsions function exactly the same way as hand washing and checking compulsions.

  Sometimes reassurance junkies directly ask for reassurance. Here are examples:

  Please guarantee me that I won’t lose my mind from anxiety.

  I’m flying tomorrow. Please tell me that I’ll be safe.

  Are you sure I won’t catch AIDS from that red spot?

  Other times, patients will ask for reassurance in a less direct manner.

  The individual with an obsessive fear of illness might ask, “Do you think I should talk to the doctor about my sore throat?”

  The person with GAD and worries about her child’s safety asks, “Do you think I did the right thing by letting my child go on the school trip?”

  The person with social anxiety asks “Do I look nervous when you come get me in the waiting room?”

  Empty Reassurance: The Sign of the Reassurance Junkie

  One sure sign of a reassurance junkie is their tendency to ask for guarantees about facts that can’t possibly be provided. Another sign is the tendency to repeatedly ask for the same or similar reassurances. These similar questions can be quite creative—and they often feel like they are different (and urgent) questions to the person who is asking them. Here are examples:

  Reassurance “junkies” ask for guarantees about facts that cannot possibly be provided.

  One patient coughed in the office and asked if she had lung cancer.

  Another continually asked for assurances that the elevator wouldn’t get stuck.

  A young woman periodically felt compelled to look at herself in the mirror and ask her mother whether she was fat. If her mother wasn’t around, she would text the same question to her boyfriend.

  Another patient constantly asked if her son was going to get a job and be able to keep it.

  Another felt susceptible to head injuries, and, every time she bumped her head— even a bump that she could acknowledge was insignificant from a health point of view—would ask for reassurance from trusted companions that she was okay and didn’t need medical attention.

  Asking for reassurance is sometimes subtle. Patients can ask outright, but they also judge the other’s reaction and look for signs of uncertainty in answers. It is easy for the therapist to get caught off guard by a sharp-eyed patient who first asks for empty reassurance, and then questions your response. Every answer is scrutinized, and minor differences or contradictions between answers are often seized upon. Excessive fact checking is another way that highly anxious people look for reassurance.

  The therapist’s job is twofold. First, to recognize the varieties of reassurance— patients don’t always overtly ask if they will be okay—and, second, to find the right level of support in the moment, while keeping an eye on the longer range goal of helping your patient get over their anxiety disorder. Make the distinction explicitly to the patient between reassurances that are informational, and those that are empty. A general rule is to provide information that is comforting once or twice, but, no more. After that, treatment should focus on the process more than content. A therapist can say something like, “There’s that ‘what if?’ thought again. Quite amazing how persistent it is, isn’t it?” Withholding reassurance gently, explicitly, and supportively teaches the patient in the moment how they are attempting to avoid facing their own internal anxious experience.

  Helping a Reassurance Junkie

  The most effective way to proceed is to provide a meta-analysis of the compulsive need for reassurance. An aspect of this approach is to explain to patients the double-edged nature of reassurance, and ask them how many of their behaviors qualify as empty reassurance. Almost every patient can identify the reassuring nature of these interactions. Most realize that they are ridiculous and readily accept that they are reassurance junkies, but feel powerless to stop.

  Provide the patient with a meta-analysis of the compulsive need for reassurance.

  Patients also readily acknowledge that their demands for reassurance are driving family and friends away. It is very valuable to devise a way to alert the home-based reassurers—who are just trying to help—that their reactions are an aspect of what maintains the problem, and to teach them alternative ways of responding. This can be a conjoint session or two, or it can be the patient’s responsibility to explain the rationale for asking to be deprived of reassurance even when he might be pleading for it—and to try to do this in a compassionate (or humorous) manner. One patient explained to his wife that his requests for reassurance were just quack questions, and they both decided that she would honk a silly quacking toy if the question “quacked like a duck,” since they were both ready for this route out of reassurance addiction. Other ideas for family: “May I hug you instead of answer that question? This must be awful for you.” Or “I love you too much to get started with that ‘what if?’ stuff.”

  It is sometimes helpful to issue patients reassurance coupons that can be used between sessions. Patients receive a limited supply that be budgeted as they desire. With children, any remaining coupons can be traded in for a reward. Both children and adults love stickers! (C. Robbins, personal communication, August 13, 2013).

  It is helpful to let patients determine how much reassurance they are going to get— or as sometimes stated in session—to let them decide the speed of their detox regime. Sometimes it is surprisingly easy. The patient who texted everyone immediately after any disagreement to apologize in case she upset them, agreed to wait one hour before texting. The next session she triumphantly reported that it was far easier than expected, several times she forgot about texting, and, one time, someone actually texted her to apologize—something that she couldn’t remember ever happening!

  References

  Gray, J. A. and McNaughton, N. (2003) The neuropsychology of anxiety. An enquiry into the functions of the septo-hippocampal system. New York, NY: Oxford University Press.

  Rosenbaum, J. F., Pollock, R. A., Jordan, S. K., and Pollack, M. H. (1996) The pharmacotherapy of panic disorder. Bulletin of the Menninger Clinic 60(2 Suppl. A) A54–75.

  Weekes, C. (1976) Simple, effective treatment of agoraphobia. New York, NY: Hawthorne Books.

  13

  Some Hard to Treat Problems

  A New Perspective

  Illness Worries (Health Anxiety and Hypochondria)

  Many anxious people focus their anxiety on their health. As with other situations in which there can be no guarantees or certainty, ha
ving something wrong with their own (or a loved one’s) body can become a full-time preoccupation. There are three distinct kinds of illness worries requiring three different treatment approaches.

  There are three distinct kinds of illness worries requiring three different treatment approaches.

  Undiagnosed Panic Disorder

  In undiagnosed panic disorder, patients worry that their dramatic physical symptoms cannot possibly just be due to anxiety and they turn up in emergency rooms (ERs) while hyperventilating, with chest pain, and fearing they are in the middle of a heart attack, stroke, or some other catastrophic medical event. The fact that they had a recent medical work-up following a previous ER visit does little to convince them that this time it really is not an emergency. Unfortunately, these patients are often discharged from the hospital with many dire illnesses ruled out, but nothing specific ruled in. Sometimes an exotic (and highly unlikely) medical condition is mentioned, thereby starting another round of anxieties, panic attacks, and emergency room visits. What is most problematic is that often they receive no guidance as to how to seek specific help: they are diagnosed with “atypical chest pain” or “anxiety,” but no positive diagnosis in a helpful form, e.g., “You have panic disorder, which is not dangerous, mimics heart attacks and is highly treatable,” along with a referral to a specialist. Otherwise, the patient is likely to be back to an ER, and may very well engage in the “million dollar workup” designed to rule everything out without necessarily coming up with a definitive diagnosis.1